PRP Diagnostic Imaging 						Your Doctor has recommended you use PRP
IMAGING REQUEST								Diagnostic Imaging. You may choose another                 												provider but please discuss with your Doctor first.
 
PATIENT
Name: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>
Contact Number: <<Patient Demographics:Phone (Home)>>     Mob: <<Patient Demographics:Phone (Mobile)>>
Medicare Number: <<Patient Demographics:Medicare Number>>    Exp Date: <<Patient Demographics:Medicare Expiry Date>>

EXAMINATION
<<Examination details of patient?>>

	

CLINICAL NOTES
<<Clinical Details:History List>>

<<Clinical Details:Medication List>>

If patient requiring IV contrast, recent Creatinine level/eGFR:  <<Enter recent Creatinine here>>

REFERRING DOCTOR
Name: <<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>
Practice Name: <<Practice:Name>>
Practice Address:<<Practice:Address>>
Practice Phone: <<Practice:Phone>>	

Date: <<Miscellaneous:Date>>   Signature:
Workers Comp:  <<Workers Comp?>>	

Film & Report:
To Patient:   <<Report to patient?>>	Deliver:   <<Report to be delivered?>>	Fax: <<Enter Fax number if report needs to be faxed?>>	More Request Forms:   <<More request forms? >>	
email:  <<Report to email?>>	Phone:  <<Report to be phoned?>>	CC: <<Enter Doctors that need to be CC into the report?>>	Request for PRP online images:   <<Request for PRP online images?>>	

PRACTICE LOCATIONS
BATHURST
117 Bentinck Street
Bathurst NSW 2795

T: 6331 3200
F:   6331 3099
bathurst@prpimaging.com.au	DUBBO
47-59 Wingewarra St
Dubo NSW 2830

T: 6882 4888
F:   6882 3688
dubbo@prpimaging.com.au	ORANGE
entry via sale St carpark
131-135 Summer Street
Orange NSW 2800

T: 6376 9000
F:   6361 9461
orange@prpimaging.com.au	

MANUALLY ENTER YOUR REQUESTS DETAILS BELOW:
X-Ray      <<X-ray?>>
CT          <<CT Scan?>>
MRI        <<MRI?>>
Ultrasound    <<Ultrasound?>>
3D Mammography / digital Breast Tomosynthesis   <<3D Mammography / digital Breast Tomosynthesis >> + ultrasound   <<+ ultrasound>>  _______________	Instructions:
Routine Investigation:   <<Routine Investigation?>>
Urgent Report  <<Urgent Report?>>
 - Ph: <<Enter phone number for Urgent report (if applicable)>>	
Is there any known contraindicatoin to:
Iodine?      <<Any known contraindication to Iodine?>>   
Barium?    <<Any known contraindication to Barium?>>
Other Drugs?  <<Any known contraindication to other Drugs>>
Please list     <<Please list other drugs>>	OFFICE USE
Appointment:
Arrived:
Prev. X-ray:
Account:

PREPARATION FOR PATIENTS
Some examinations require special preparation. 
Please ask your local PRP practice when making your appointment or visit prpimagingcom.au

CARDIAC PERFUSION
CT
CT ANGIOGRAPHY
CT CORONARY ANGIOGRAPHY
SPECT / CT
BONE DENSITY / DEXA
DEXA/TOTAL BODY
COMPOSITION
MEASUREMENT
DIGITAL X-RAY
DIGITAL OPG
DOPPLER
ECHOCARDIOGRAPHY
EXERCISE STREEE TEST 
IMAGE GUIDED BIOPSY
MAMMOGRAPHY / 3D BREAST TOMOSYNTHESIS
MRI
MSK INJECTION
NUCLEAR MEDICINE / MOLECULAR IMAGING
SPINAL INJECTION
ULTRASOUND	APPOINTMENT

Time: 
______________________________________
Date:
______________________________________
Practice: 
______________________________________

PLEASE BRING ALL RELEVANT FILMS.	

www.prpimaging.com.au                                                        Your local medical imaging partner